Engaging informal providers in Bangladesh

Dr. Mahfuza MousumiProject Manager, Health & NutritionSave the Children, BangladeshEmail: mahfuza.mousumi@savethechildren.org

Stakeholders’ consultation on Informal Service ProvidersOrganized by: CReNIEO

Chennai in India21-22 March 2014

Presentation Outline

Child health situation in Bangladesh CCM Project overview Village Doctors engagement

experinaces Program results Lessons learned

Trends in under-5 child mortality in Bangladesh

1989-93 1992-6 1995-9 1999-2003 2002-6 2007-11 2015

52 48 42 41 37 32 21

35 3424 24 15 10

10

4634

28 2313

11 17

133116

94 8865 53 48

Neonatal Deaths/1,000 LB1-11 Month Deaths/1,000 LB12-59 Month Deaths/1,000 LB

MDG Target

Deat

hs p

er 1

,000

live

-bi

rths

Source: BDHS 2011

Distribution of under-5 deaths in Bangladesh by causes of deaths: 2006-2011

Source: BDHS 2011

Pneumonia

Possible serious infection

19%

22%

15%

13%

9%

7%

2% 7% 6%

Possible

serious infectio

n

Undefined

Other neona-

talOther

DrowningPneumonia

Pneumonia Treatment Status (BDHS 2011)

50% care seeking for Pneumonia from drug stores and Village Doctors (VDs)

35% of children with symptoms of pneumonia were taken to health facility or a medically trained provider

79% of the children seeing a provider were prescribed antibiotics

Presentation Outline

CCM Project overview

Project Information

Implementation area: 17sub-districts in southern part of Bangladesh

Target group : Children under five years of age (approx. 400,000)

Duration : February 2012 to April 2014 Donor : Procter & Gamble

Project strategies

MOH front line workers’ capacity

strengthening

Capacity building of VD & linkages with

formal HS

Community engagement and support mechanism

Improve access to quality services

Public/ formal

Private/informal

Community groups

Presentation Outline

Village Doctors engagement

Rationale for engagement Increase coverage of protocol Popular & common choice of

population esp. among poor HHs Village resident, available 24/7 Drugs available at the clinic (provide

drugs on easy installment) Conduct home visits

Initial considerations for VD engagement

Process of VDs selection Training & skill retention Quality Assurance

Selection of Village Doctors Service mapping (identify gap areas) Consultation with community leaders

to identify popular VDs for children U5, VDs association

Live /practice in the targeted village Willingness to participate in training

and treat children following national protocol

Not involved in political activities

Who are the selected VDs?

75% of them completed 10th grade education

Majority are between 30-50 years of age

Most of them received 3-6 months course from private institution and also worked as assistant of a doctor or VD

Nearly all operate a pharmacy

Capacity building & QA approach Revision of basic training manual specially for

VDs in partnership with IMCI unit, MOH Adaptation of standard monitoring &

supervision tools Conduct basic & refresher trainings by MOH

sub-district level MTs; 298 VDs trained on CCM (3-day) and 281 currently active

Provided essential supplies & job Aids -ARI timer, thermometer, chart booklet, treatment register, referral slips & tools.

Supportive supervision- joint supervision with MOH supervisors

Presentation Outline

Results

Number of cases treated by trained VDs

Oct’12 to Dec’13

N=199

Key findings of Supervision Visit

Correct

case

manag

emen

t

Treatm

ent c

onsis

tency

Record

keep

ing

Avail

abilit

y of d

rugs

Avail

abilit

y of s

uppli

es0

306090

Perc

enta

ge

January to December 2013

N=184

Supervision Mechanism

Post-training follow up visits: each VD supervised twice a month for initial 3 months followed by monthly supervisory visits Review register Direct observation/ case scenario Random HH visit of treated cases

Joint supervision with MOH supervisors (98% of VDs received supervision visit in the last month)

Supervision Checklist

Presentation Outline

Result: Key findings of Village Doctors assessment

Before training After training• Only 35% used

equipment (stethoscope/watch) for pneumonia diagnosis

• Diagnosis made based on symptoms

• Used higher antibiotic

• Count respiration rate using ARI timer

• Use simple antibiotic (amoxicillin)

• Referral of severe pneumonia cases

Diagnosis and treatment of pneumonia

Availability of Supplies

92% of VDs have functional ARI Timer All VDs have functional thermometer IMCI Algorithm/chart is available with

97% VDs 96% of VDs are maintaining service

registers

Drugs availability

98% of trained VDs are selling amoxicillin of recommended brands

ORS and Zinc are also available in their pharmacy

VDs attitude and practices around referral

Before training After training• Almost absent

among VDs• Perceived as

unskilled and incapable

• Financial disincentive of people seeking treatment elsewhere

• Giving preference to treatment protocol over business motive

• Refer sick children following protocol rather than doing trial and error

Referral linkage with MOH 91% of VDs are using referral slips 97% of VDs referred sick children to near

by appropriate MoH facility 88% severe/danger sign 24% diarrhea with severe dehydration 15% sick newborn

76% of VDs have mechanisms to ensure quality services/follow up

Lessons learned Low profit margin and slow recovery of treated

cases with amoxicillin is a challenge for following standard treatment protocol Refresher training, review meeting and

supportive supervision are effective ways for ensuring quality and maintain motivation

Joint supervision with MOH staff supports establishment of linkage with formal health system; adding VD treated cases in national HMIS

CCM projects created scopes for VDs engaging in other child health interventions by government & non-government programs.

Next steps

Preliminary results/experiences are promising. VDs are following protocol & maintaining guideline and referring severe cases

SC wants to expand this to additional VDs and conduct research to identify what is needed to enhance quality of pneumonia treatment by informal providers at scale

Thank You